Difficult tracheal intubation in paediatric: myth or reality?

Difficult tracheal intubation is a rare event according to the airway feature in child. This situation is mostly predictable, occurring in identified malformations and in specific diseases. Pre-operative clinical evaluation must detect facial abnormalities (lip or palate cleft, microtia, facial asymmetry.), micro or retrognathia, limited mouth opening, reduced distance between thyroid cartilage and chin, macroglossia and external ear malformations. According to this clinical evaluation, a strategy for managing difficult tracheal intubation is planned.     

Electroencephalographic mapping during routine clinical practice: cortical arousal during tracheal intubation?

We used quantitative analysis of the electroencephalogram (EEG) in 42 patients to assess the effect of tracheal intubation after induction of anesthesia with etomidate and sufentanil using standard clinical practice. The EEG was recorded from eight bipolar electrode derivations and Z-transformed relative to age expected normative data for relative power in the delta, theta, alpha, and beta frequency bands. Tracheal intubation resulted in classical cortical arousal, as indicated by acceleration of the EEG frequencies. Significant effects were seen in all frequency bands, most pronounced in the alpha frequency band, with the largest increase bilaterally in the fronto-temporal regions (F-values: Delta - 9.592, P < 0.001; theta - 1.691, P < 0.001; alpha - 18.439, P < 0.001; beta - 4.504, P < 0.001). Changes in alpha and delta power during induction of anesthesia were correlated with the dose of etomidate (P < 0.05). Changes in alpha after tracheal intubation were correlated at the parietooccipital brain regions to the dose of sufentanil (P < 0.05). Individual titration of the dose of etomidate and sufentanil, as during routine clinical practice, is not sufficient to block the strong noxious stimulation of tracheal intubation and results in cortical arousal. The clinical impact of this cortical wake-up phenomenon is undetermined.     

Esophageal perforation after tracheal intubation,spontaneous or iatrogenic?--a case report

Esophageal perforation is a rare but life-threatening complication associated with tracheal intubation, especially after difficult intubation. Esophageal perforation after anesthesia is rare and usually secondary to esophageal instrumentation. Spontaneous esophageal perforation following forceful vomiting (Boerhaave's syndrome) is also extremely rare and has some risk factors. We present a case of perforation of esophagus after cataract surgery under general anesthesia with gentle orotracheal intubation and discuss the possible mechanisms responsible for this unusual disease entity. The patient underwent successful surgical repair and was still alive 4 years after the operation.     

Live surgery: highly educational or harmful?

Purpose

Live surgery (LS) is considered a useful teaching opportunity. The benefits must be balanced with patient safety concerns. To evaluate the rate of complications of a series of urologic LS performed by experts during the Congress Challenge in Laparoscopy and Robotics (CILR).

Methods

We present a large, multi-institution, multi-surgeon database that derives from 12 CILR events, from 2004 to 2015 with a total of 224 cases. Radical prostatectomy (RP) was the most common procedure and a selection of complex cases was noted. The primary measure was postoperative complications and use of a Postoperative Morbidity Index (PMI) to allow quantitative weighing of postoperative complications.

Results

From 12 events, the number of cases increased from 11 in 2004 to 27 in 2015 and a total of 27 surgeons. Of 224 cases (164 laparoscopic and 60 robotic), there were 26 (11.6%) complications: 5 grade I, 5 grade II, 3 grade IIIa, 12 grade IIIb and 1 grade V, the latter from laparoscopic cystectomy. Analysis of PMI was 23 times higher from cystectomy compared to RP.

Conclusions

In the setting of live surgery, the overall rate of complications is low considering the complexity of surgeries. The PMI is not higher in more complex procedures, whereas RP seems very safe.

     

Difficult intubation in thyroid surgery: myth or reality?

Thyroid surgery is considered to be a risk factor for difficult airway management. We prospectively studied 324 consecutive patients undergoing thyroid surgery to investigate the incidence of difficult intubation as evaluated by the intubation difficulty scale as well as other specific predictive factors. The overall incidence of difficult intubation was 11.1% (95% CI: 7.6-14.5). Median intubation difficulty scale was 0 (25th-75th percentile: 0; 2.7). In three predefined groups (no echographic goiter, clinically palpable goiter, and impalpable goiter), difficult intubation occurred in 10% (95% CI: 4.8-17.4), 13% (95% CI: 6.5-18.4), and 11% (95% CI: 4.7-16.8) of patients, respectively, with no statistical difference among the groups. Specific predictive criteria (palpable goiter, endothoracic goiter, airway deformation, airway compression, or thyroid malignancy) were not associated with an increased rate of difficult intubation. Classical predictive criteria (mouth opening <35 mm, Mallampati III or IV, short neck, neck mobility <80 degrees , thyromental distance <65 mm, and a retrognathic mandible) were significantly reliable in the univariate analysis as risk factors for difficult intubation.     

Steroid utilization in eosinophilic jejunitis: beneficial or harmful?

Purpose  

Eosinophilic jejunitis is a rare disorder of undetermined origin, which is characterized by infiltration of eosinophils in the intestine. The aim of this study is to evaluate steroid therapy effect in patient treated for eosinophilic jejunitis to share our experience with other colleagues.     

The unanticipated difficult intubation: rigid or flexible endoscope?

BACKGROUND: Unanticipated difficult intubation occurs with a frequency between 1.5% and 8.5%. The aim of this study was to compare the use of flexible versus rigid endoscopy in such a patient population, with respect to the preparation time and feasibility of each device. METHODS: During a four-year observational period, 116 patients with unanticipated difficult intubation were managed either with the flexible fiberscope (FFI group, n= 57) or the rigid Bonfils endoscope (RBI group, n= 59) on a randomized basis. RESULTS: The time required for preparing and performing the intubation was significantly shorter in the RBI group: median (IQR) 160 s (118-209 s) as opposed to 229 s (162-326 s) in the FFI group (P=0.001). There were no significant differences with respect to endoscopic visibility or quality of the intubation manoeuvre (P>0.1 each). Causes of unanticipated difficult intubation were mainly as follows: restricted movement of the head and neck (39.7%), a Mallampati class > 2 (35.3%), a short neck (31%) or a thyromental distance < or = 5 cm (28.4%). Postoperative complications associated with the intubation maneuver included slight bleeding (FFI = 8.8% vs RBI = 8.5%; NS), technical problems (12.3 vs 10.2%, NS), hoarseness (15.8 vs 15.3%, P=0.946) and dysphagia (5.3 vs 16.9%, P=0.070). CONCLUSION: Both endoscopic techniques enable quick and safe intubation. The Bonfils method could be the method of choice in cases of already relaxed patients with unanticipated difficult conventional laryngoscopy, presuming that the anaesthetist is familiar with this technique. Because the clinical re-evaluation for possible predictors of difficult intubation revealed no unknown new factors, the preoperative examination for anatomical peculiarities and being aware are the best protection against unanticipated intubation problems.     

Routine ileal intubation during screening colonoscopy: a useful maneuver?

Background  The utility of routine ileoscopy as a component of screening colonoscopy is unclear. Many endoscopists believe that routine intubation of the terminal ileum is a requirement for a full-screening colonoscopy. The authors have hypothesized that routine ileal intubation during screening colonoscopy is of little diagnostic value. Methods  A retrospective analysis was performed using a prospectively maintained colonoscopy database of patients identified as undergoing a screening colonoscopy. All had undergone intubation of the terminal ileum at a tertiary referral center. Those who had undergone screening colonoscopy at the Mayo Clinic (Rochester, MN) were entered prospectively into a database. The study identified 6,408 patients who met the criteria of having terminal ileal intubation at the time of screening colonoscopy. The main outcome measured was abnormality of the terminal ileum at ileal intubation. Results  Ileoscopy showed grossly abnormal findings for only 1% of the patients, and pathologic abnormalities were identified for only 0.3% of all the patients. Conclusions  The findings support the conclusion that intubation of the terminal ileum should not be a required part of screening colonoscopy.